摘要
目的利用PDCA循环寻找导致病案未及时归档的原因并制定相应的改进措施,从而提高出院病案的3日归档率。方法将某三甲医院PDCA实施前2019年1月1日-2019年12月31日的住院病案作为实施前组,PDCA实施后2020年1月1日-2020年12与31日住院病案作为实施后组。比较PDCA实施前后病案归档情况。结果PDCA实施后3日归档率为97.31%,比实施前上升23.87%,差异有统计学意义。PDCA项目目标达标率为89.87%。PDCA实施后超3日归档的病案数为1157份,比PDCA实施前减少12673份,进步率为91.63%。结论PDCA循环的实施,增加激励力度、制定统一工作方案、优化病案签收流程和多样化沟通反馈方式是促进病案及时归档的有效措施,可不断解决病案迟归的问题,为医疗质量持续改进奠定基础。
Objectives The PDCA cycle was used to find out the reasons that led to the failure of timely archiving of medical records and make corresponding improvement measures,so as to improve the 3-day archiving rate of discharged medical records.Methods The hospitalization records from January 1st,2019 to December 31st,2019 in a Three A and Tertiary hospital before the implementation of PDCA were taken as the pre-implementation group,and the hospitalization records from January 1st,2020 to December 31st,2020 after the implementation of PDCA were taken as the post-implementation group.The medical record filing before and after THE implementation of PDCA was compared.Results After the implementation of PDCA,the archiving rate of 3 days was 97.31%,23.87% higher than before,and the difference was statistically significant.The target rate of PDCA project was 89.87%.After the implementation of PDCA,the number of medical records filed more than 3 days after the implementation of PDCA was 1157,which was 12673 fewer than that before the implementation of PDCA,and the improvement rate was 91.63%.Conclusions The implementation of PDCA cycle,increasing incentive strength,formulating unified work plan,optimizing medical record signing process and diversified communication and feedback methods were effective measures to promote timely archiving of medical records,which could continuously solve the problem of late return of medical records and lay a foundation for continuous improvement of medical quality.
作者
于磊
熊小兰
钟慧翔
杨建荣
黄东怡
钟小兰
Yu Lei;Xiong Xiaolan;Zhong Huixiang;Yang Jianrong;Huang Dongyi;Zhong Xiaolan(Huadu District People's Hospital Affiliated to Southern Medical University,Guangzhou 510800,Guangdong Province,China;不详)
出处
《中国病案》
2021年第11期4-6,24,共4页
Chinese Medical Record
基金
南方医科大学附属花都医院科研基金(2020C01)
广州市花都区医疗卫生一般科研专项项目(20-HDWS-022,20-HDWS-023)。
关键词
PDCA
归档率
病案归档
PDCA
Archiving rate
Medical record archiving
